Teen vaping in Australia Does it increase smoking risk? Nicola Guerin1 & Vicki White2 1 Centre for Behavioural Research in Cancer, Cancer Council Victoria, VIC 2 School of Psychology, Deakin University, VIC The focus of the work I’m talking about today is student vaping, or e-cigarette use and experience, and how it relates to smoking traditional cigarettes. My co-author is Vicki White Funded by the Commonwealth Department of Health & the Victorian Department of Health and Human Services © Cancer Council | 24 October 2019 | Nicola.Guerin@cancervic.org.au

Background – US, UK, Canada 2000s: E-cigs introduced Rapid development & marketing 2010s: E-cig marketing targets youth Adolescents 1984-2017: smoking 2017-2019: vaping In countries comparable with Australia, vaping marketing and prevalence rose rapidly during the 2000s, with products mimicking cigarettes, and advertising often targeting young people. In these countries, vaping is more common among teenagers who smoke than non-smokers. Vaping uptake by teenagers has continued to rise…. (with continued concern about vaping as a gateway to cigarette smoking or more regular smoking)

Background – US, UK, Canada 2000s: E-cigs introduced Rapid development & marketing Does vaping lead to smoking among teenagers? 2010s: E-cig marketing targets youth Does vaping keep teenagers smoking? Adolescents 1984-2017: smoking 2017-2019: vaping …with continued concern about vaping as a gateway to cigarette smoking or more regular smoking

Background – US, UK, Canada Australia 2000s: E-cigs introduced Rapid development & marketing Does vaping lead to smoking among teenagers? 2010s: Growth of e-cig marketing (particularly online) Marketing targets youth Does vaping keep teenagers smoking? Adolescents 1984-2017: smoking 2017-2019: vaping These questions have also been asked in Australia. Should we be alarmed about adolescent vaping in Australia?

Australia 1984-2017 Adolescent smoking 2012 Plain packaging E-cigarette marketing 2011 2014 2017 TIGHTER E-CIG RESTRICTIONS Banned retail sale of nicotine e-cigarettes (prescription only) Restricted retail display Banned sale to minors in most states & territories 2013-2016 Vaping 18-24yo adults 19% ever vaped 49% smokers ever vaped We have a unique legislative context. Adolescent smoking has declined steadily since 1984, including after plain packaging was introduced in 2012. At that time, tobacco companies started marketing e-cigarettes and other novel products to boost slow cigarette sales. However, unlike overseas, Australian governments quickly restricted the sale and advertising of vaping products. Restrictions vary across Australian states but have generally continued to tighten Adolescents cannot buy vaping products legally Adults cannot legally buy nicotine e-liquid without a medical prescription However, among young adults, vaping increased between 2013 and 2016: 19% of 18-24 had ever used e-cigarettes in 2016, and 49% of smokers having ever used them.

Research Questions Did vaping increase among teenagers 2014-2017? How was smoking related to e-cigarette use? Given this unique background, we examined how smoking and vaping are related among adolescents in Australia. We asked: Did vaping increase among teenagers 2014-2017? How was smoking related to e-cigarette use?

Sample Secondary students aged 12-17 2014 N=23,007 2017 N=19,115 Study Design Sample Secondary students aged 12-17 2014 N=23,007 2017 N=19,115 Method 2 cross- sectional national surveys Key measures Smoked Vaped Ever Past month Our data are from two national cross-sectional population surveys of Australian secondary students. Our key measures were ever and past month vaping and smoking

Did vaping increase among Australian teenagers 2014-2017? 14% 12-17 year-olds ever vaped past month vaping among ever-vapers 25% 2014 31% 2017 No significant change 2014 - 2017 Did vaping increase between 2014 and 2017? Around 14 % of students had ever vaped in 2014, and this did not change significantly to 2017 Among students who had ever vaped, recent vaping was more common in 2017 than 2014. So, while the proportion of students who had ever tried vaping had not changed, students who had vaped tended to be vaping more regularly. 2014-2017: increase in recent vaping among ever-vapers OTCC 2019

Which students had vaped recently? Among ever-vapers, 2017 past month vaping 34% 12-15yo 27% 16-17yo Among ever-vapers, 2017 ≥ three occasions in the past month 16% 12-15yo 10% 16-17yo Looking only at students who had ever vaped, past month use was more common among younger than older students. This finding could have been because younger students who had tried vaping were more likely to have tried it recently, while older students might have experimented with it at a younger age themselves However, regular vaping was also more common among younger students than older students. So, younger vapers were becoming more regular users than older students who had tried it. OTCC 2019

Which students had vaped recently? Among ever-vapers, 2017 past month vaping 34% 12-15yo 27% 16-17yo Among ever-vapers, 2017 ≥ three occasions in the past month 16% 12-15yo 10% 16-17yo But how many of these students had also smoked? How many vapers also smoked? OTCC 2019

How many had ever smoked? 7 in 10 ever vapers had smoked 7 in 10 2 in 10 students had ever smoked 2 in 10 1 in 10 never vapers had smoked Around 68% of vapers had ever smoked. This compares to 18% of all students who had ever smoked, and only 10% of students who had never vaped had ever smoked 1 in 10 OTCC 2019

How many had ever smoked? 7 in 10 ever vapers had smoked 7 in 10 2 in 10 students had ever smoked Had they vaped first? Or smoked first? 2 in 10 1 in 10 never vapers had smoked What we don’t know is, are students who vape more likely to later smoke than students who don’t experiment? 1 in 10 OTCC 2019

How many, if any, cigarettes had you smoked before vaping? Had they vaped first? Or smoked first? How many, if any, cigarettes had you smoked before vaping? Around half had vaped first 41% & 53% vaped first (2017) How many past month vapers also smoked in the past month? 2014 43% 2017 48% In 2017, students who had vaped were asked how many, if any, cigarettes they had smoked before vaping. Around half of those who had both vaped and smoked had first vaped Looking at past month vaping, we see that the percentage of past month vapers who were also current smokers increased in 2017. We do note that the change in wording between 2014 and 2017 about past month use could have affected response patterns. So, in 2017, a higher proportion of regular vapers were also regular smokers. But did vaping lead to smoking? Or the other way around? Or was there a common liability? OTCC 2019

Was regular smoking more common among students who had first vaped? Vaped first (and later smoked/did not smoke) 11% 7% Smoked in the past month Smoked first (and later vaped) To look at whether vaping first increased the likelihood of later smoking in 2017, we compared the prevalence of past month smoking among two key sub-groups: 1. students who had vaped before ever trying a cigarette, or before never trying a cigarette 2. students who had never vaped, or students who had smoked first before ever trying an e-cigarette. Comparing these two groups, we found that 11% of vape-first students had smoked in the past month. This was significantly more than the 7% of smoke-first or never-vapers who had smoked in the past month. Never vaped (and later smoked/did not smoke) OTCC 2019

So what? Australia 2014-2017 No increase in ever-vaping Increased past month vaping Teenagers who vaped were more likely to also smoke & smoke regularly Vaping first  higher smoking risk Overall, our key findings are that in while we are not seeing the increase in ever vaping found in the other countries, more teenagers are vaping regularly Teenagers who vaped were more likely to smoke & smoke regularly Vaping first  higher risk of smoking 15 OTCC 2019 This Photo by Unknown Author is licensed under CC BY-SA

So what? Questions Is vaping an indicator of smoking risk or a risk factor? Access to vapes? Social environments of use? Recommendations Continue to restrict access/exposure to products and marketing Monitor online access Provide health education about vaping Longitudinal studies are needed to evaluate the effect of vaping on smoking risk. We need to ask adolescents more about how they are accessing vaping supplies, and how are they using them – for example, is vaping a party or a solo activity? Is it related to alcohol and other drug use? Is it related to cigarette prices? These findings provide strong evidence that legislative restrictions have been comparatively effective in limiting limited adolescent vaping, but substantial numbers of adolescents are experimenting with vaping and the ease of accessing vaping supplies online is a substantial risk. Greater health education about the relative risks of vaping is needed. With the substantial uptake of vaping, it will be important to monitor developments that might re-normalize smoking and increase the teenage smoking risk. Nicola.Guerin@cancervic.org.au 16 OTCC 2019 This Photo by Unknown Author is licensed under CC BY-SA